Citation Nr: 21015622 Decision Date: 03/17/21 Archive Date: 03/17/21 DOCKET NO. 20-26 314 DATE: March 17, 2021 ORDER The appeal as to the issue of an initial rating greater than 10 percent for tinnitus is dismissed. The appeal as to the issue of an effective date earlier than May 8, 2018, for the award of service connection for hearing loss is dismissed. The appeal as to the issue of an effective date earlier than May 8, 2018, for the award of service connection for tinnitus is dismissed. Service connection for a heart condition is denied. New and material evidence having been received, the claim of service connection for a skin condition is reopened. New and material evidence having been received, the claim of service connection for a low back disability is reopened. REMANDED The issue of service connection for a skin condition is remanded. The issue of service connection for a low back disability is remanded. The issue of service connection for a right knee disability is remanded. The issue of service connection for a right knee disability is remanded. The issue of service connection for an eye condition is remanded. The issue of an initial compensable rating for hearing loss is remanded. FINDINGS OF FACT 1. During a January 2021 Board of Veterans’ Appeals (Board) hearing, prior to the promulgation of a decision by the Board in this appeal, the Veteran withdrew from appeal the claims for a higher initial rating for tinnitus, as well as for earlier effective dates for the awards of service connection for hearing loss and tinnitus. 2. In a December 2015 rating decision, a Department of Veterans Affairs (VA) Regional Office (RO) denied service connection for a skin condition and for a low back disability; the Veteran did not appeal that decision and it became final. 3. Since the December 2015 final rating decision, evidence has been associated with the claims file that is not duplicative or cumulative of evidence previously of record, and that relates to unestablished facts necessary to substantiate the claims for service connection for a skin condition and for a low back disability. 4. The evidence fails to suggest that the Veteran has a diagnosed heart condition that was incurred in or is otherwise related to service. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the appeal as to the issue of an initial rating greater than 10 percent for tinnitus are met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 2. The criteria for withdrawal of the appeal as to the issue of an effective date earlier than May 8, 2018, for the award of service connection for hearing loss are met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 3. The criteria for withdrawal of the appeal as to the claim for an effective date earlier than May 8, 2018, for the award of service connection for tinnitus are met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 4. The December 2015 rating decision, in which the RO denied service connection for a skin condition and a low back disability is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.156(b), 20.1103. 5. As evidence received since the December 2015 rating decision is new and material, the criteria for reopening the claim for service connection for a skin condition have been met. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156. 6. As evidence received since the December 2015 rating decision is new and material, the criteria for reopening the claim for service connection for a low back disability have been met. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156. 7. The criteria for service connection for a heart condition have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from October 1954 to July 1956. This appeal to the Board arose from a September 2018 rating decision in which the RO granted service connection for hearing loss, evaluated as noncompensably disabling, effective from May 8, 2018; granted service connection for tinnitus, evaluated as 10 percent disabling, effective from May 8, 2018; denied service connection for eye problems, a heart condition, and right and left knee conditions; and determined that new and material evidence sufficient to reopen previously denied claims for service connection for a skin condition and a low back disability had not been submitted. The Veteran disagreed with that decision, to include with the disability ratings and effective dates assigned in connection with the grants of service connection for hearing loss and tinnitus, and subsequently perfected an appeal to the Board. In January 2021, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge; a transcript of the hearing has been associated with the claims file. Regarding the claims involving a skin condition and a low back disability, as discussed below, the Board must first decide whether new and material evidence to reopen the claims for service connection for a skin condition and a low back disability has been received See Barnett v. Brown, 83 F.3d 1380, 1383 (Fed. Cir. 1996). Given the favorable disposition, below, on the requests to reopen, the Board has characterized the appeal as encompassing both the requests to reopen and the underlying service connection claims, as set forth above. Dismissal The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 19.55. Withdrawal may be made by a claimant or by his or her authorized representative. Id. Here, during his January 2021 Board hearing, the Veteran explicitly, unambiguously, and with a full understanding of the consequences, requested to withdraw from appeal the claims for an initial rating greater than 10 percent for tinnitus and for effective dates earlier than May 8, 2018, for the grants of service connection for tinnitus and hearing loss. As no allegations of errors of fact or law remain for appellate consideration regarding these matters, the Board does not have jurisdiction to review these claims, and they must be dismissed. Service Connection The law provides that service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304. Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires competent evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the current disability and an in-service precipitating disease, injury or event. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In addition, certain chronic diseases, including hypertension, may be presumed to have been incurred during service if the disorder becomes manifest to a compensable degree within one year of separation from active duty. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Alternatively, for chronic diseases, to include hypertension, the second and third elements of service connection may be established for certain chronic disease through demonstrating chronicity or continuity of symptomatology in accordance with 38 C.F.R. § 3.303(b). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (38 C.F.R. § 3.303(b) only applies to the listed chronic disabilities in 38 C.F.R. § 3.309 (a)); Savage v. Gober, 10 Vet. App. 488, 495-96 (1997). At the outset, the Board notes that the Veteran has provided little information concerning the exact nature of his claim for service connection for a heart condition or his theory of entitlement. Thus, the Board will consider generally whether the evidence supports a finding of service connection for any diagnosed heart condition. See Clemons v. Shinseki, 23 Vet. App. 1, 5-6 (2009) (requiring consideration of alternative disabilities within scope of claim). A review of the Veteran’s post-service medical records shows that the Veteran has been diagnosed with various heart-related conditions, to include hypertension, coronary artery disease, and congestive heart failure, and atrial fibrillation. The Board notes, initially, that the Veteran’s service treatment records (STRs) were among those thought to have been destroyed in a 1973 fire at National Personnel Records Center (NPRC). Of record, however, is a copy of the Veteran’s July 1956 separation examination report, which report reveals that the Veteran’s heart was clinically evaluated as normal at the time of examination. The Veteran’s post-service medical records show that the Veteran was evaluated for complaints of chest pain in July 2014. At that time, he was assessed as having mild left ventricular hypertrophy, borderline left atrial enlargement, and aortic valve sclerosis without significant stenosis or regurgitations. A diagnosis of hypertension was also of record at that time, although it is not indicated when such diagnosis was first rendered. Additional testing conducted in August 2014 revealed no acute process, but an echocardiogram indicated atrial fibrillation. Records dated in February 2017 show that the Veteran had undergone a recent bypass surgery; it was noted that the Veteran had been experiencing chest pain for approximately one year at the time. The Veteran was diagnosed with coronary artery disease, status post coronary artery bypass; other treated diagnoses were noted to include hypertension and diastolic congestive heart failure. During his January 2021 Board hearing, the Veteran reported having undergone a heart operation. When asked whether any clinician had discussed with him whether his heart condition was related to service, he answered in the negative. The Veteran also reported the onset of hypertension to have been 15 years prior. No additional information was reported during the hearing. Notably, in the instant case, the Veteran has proffered no theory of entitlement to service connection for a heart condition, to include indicating the onset of heart-related symptoms in or shortly after service or identifying any in-service incident to which he believes any current heart condition is related. Indeed, short of applying for service connection for heart condition, the Veteran has provided no basis for why he believes service connection for a heart condition is warranted. Upon review of the record, the Board finds that although the evidence reveals that the Veteran has been shown to have various diagnosed heart-related conditions, there is simply no evidence to suggest that any diagnosed heart condition is in any way related to service. Notably, the Veteran’s heart was clinically evaluated as normal at the time of his 1956 separation examination and the Veteran has not alleged that he suffered from any heart condition or related symptoms in service. The Veteran has also not alleged any in-service incident to which he believes any heart condition may be related. Further, the Veteran has not indicated that any medical professional has suggested that any noted heart condition may be related to service and the Veteran has proffered to no evidence, to include any lay evidence, that suggests that any diagnosed heart condition may be attributable to service. Furthermore, although it is not clear from the Veteran’s medical records when he was first diagnosed with hypertension, at his January 2021 hearing, the Veteran reported the onset of hypertension to have been about 15 years prior. Based on this evidence, there is no indication that hypertension manifested to a compensable degree within one year of the Veteran’s separation from military service in 1956. Accordingly, the one-year presumption for hypertension under 38 C.F.R. §§ 3.307 and 3.309 is not helpful, nor are the provisions of 38 C.F.R. § 3.303(b) pertaining to chronicity or continuity of symptomatology. Service connection is therefore not warranted for hypertension on a presumptive basis for chronic diseases. See 38 U.S.C. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307(a)(3); 3.309(a). In short, there is no basis upon which to conclude that the Veteran’s has a diagnosed heart condition that is in any way directly attributable to service. Indeed, not only has the Veteran not identified a heart condition, or related symptomatology, in service, the Veteran has not indicated any specific event or injury in service to which he attributes his current disability. Thus, in light of the Veteran’s own statements, or lack thereof, and the medical evidence of record, there is no basis to establish service connection for a diagnosed heart condition, as two crucial elements of service connection have not been shown. See Davidson, supra. In so finding, the Board acknowledges that the Veteran was not afforded a VA medical examination in connection with his claim. The Board also acknowledges that the Veteran’s STRs are fire-related and that VA’s duty to assist is therefore heightened. See Russo v. Brown, 9 Vet. App. 46, 51 (1996) (holding that caselaw establishes a “heightened duty” to assist when the appellant’s medical records have been lost or destroyed); Moore v. Derwinski, 1 Vet. App. 401, 406 (1991) (holding that VA’s duty to assist is “particularly great in light of the unavailability of the veteran’s exit examination and full Army medical records”). The Board has considered whether the VA’s duty to assist in this regard was triggered but finds that it was not because evidence suggesting a link between any of the Veteran’s heart conditions and service is lacking. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006) (discussing the evidence required to trigger VA’s duty to provide a medical examination or obtain a medical opinion); see also Waters v. Shinseki, 601 F.3d 1274, 1278-79 (Fed. Cir. 2010) (rejecting appellant’s argument that his conclusory generalized statement that his service illness caused his present medical problems was enough to entitle him to a medical examination under the standard of [38 U.S.C. § 5103A(d)(2)(B)]). Again, the Board points out that the Veteran has not provided any information regarding his theory of entitlement to service connection, to include any description of the injury or event sustained in service that contributed to any current heart condition. The Veteran’s attorney has also provided no argument in support of the Veteran’s claim for service connection a heart condition, to include during the January 2021 Board hearing or in the June 2020 appellate brief. Requests to Reopen The record reflects that the RO previously denied the Veteran’s claims for service connection for a skin condition and for a low back disability in December 2015. The RO notified the Veteran of the denials that same month; however, the Veteran did not initiate an appeal by filing a notice of disagreement within one year. See 38 C.F.R. §§ 20.200, 20.201. Also, no new and material evidence for either claim was associated with the claims file within one of year the denials, and no additional service records have been associated with the claims file at any time, warranting readjudication of the claim. See 38 C.F.R. §§ 3.165(b), (c). Therefore, the December 2015 rating decision is final as to the evidence then of record, and is not subject to revision on the same factual basis. See 38 U.S.C. § 7105(c); 38 C.F.R. § 20.1103. Thus, as a result of the finality of the December 2015 rating decision, the Veteran’s claims for service connection for a skin condition a or a low back disability may now be considered on the merits only if new and material evidence has been received since the time of the last final denial. 38 U.S.C. §§ 5108, 7104; Evans v. Brown, 9 Vet. App. 273 (1996); Manio v. Derwinski, 1 Vet. App. 140, 145 (1991); 38 C.F.R. § 3.156. Section 3.156(a) of title 38, Code of Federal Regulations provides the following definitions of new and material evidence: New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In making the determination of materiality, the credibility of the evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). To determine whether new and material evidence has in fact been submitted, the Board first must compare the evidence submitted since the previous final denial with evidence previously of record. If the newly submitted evidence is that which was not of record at the time of the last final disallowance (on any basis) of the claim, and is not merely cumulative of other evidence that was then of record, it will be considered new evidence under 38 C.F.R. § 3.156(a). If the evidence is in fact new, the Board will then consider whether it is also material. In this regard, the Board notes that the threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is low. Shade v. Shinseki, 24 Vet. App. 110, 117. When evaluating the materiality of newly submitted evidence, the focus must not be solely on whether the evidence remedies the principal reason for denial in the last prior decision; rather the determination of materiality should focus on whether the evidence, taken together, could at least trigger the duty to assist or consideration of a new theory of entitlement. See id. at 118, 124 (Lance, J. concurring). Notably, the evidence of record at the time of the December 2015 final rating decision failed to suggest that the Veteran had a skin condition and/or low back disability that was incurred in or otherwise caused by service. Indeed, although the record showed treatment for low back pain and a diagnosis of lumbar spondylosis, the record contained no information regarding any in-service incident to which the Veteran attributed his back disability. Additionally, the record contained no documented diagnosis of a skin condition or any evidence to suggest that the Veteran had a skin condition that may be related to service. During his January 2021 hearing, the Veteran testified regarding his claims for service connection for a skin condition and for a low back disability. Specifically, the Veteran reported that while stationed in Germany, he was treated in service for psoriasis; he further reported monthly flare-ups of psoriasis since that time. (Parenthetically, the Board notes that the Veteran’s DD Form 214 confirms his overseas service in Germany). The Veteran also reported that he began to have back problems in service, to include having injured his back while stationed in Germany. The Veteran stated that he was carrying heavy items, such as tents and generators, to the filed for training exercises, which he believes led to his back problems. He stated that he did not seek treatment at the time, but has had pain in his back ever since. The Board finds that the lay testimony, which is presumed credible for purposes of determining if it is material, see Justus, supra, is new in that it was not previously before VA adjudicators, and is not cumulative or duplicative of other evidence. The evidence is also material, in that it is relevant to the question of the whether the Veteran has a current diagnosis of a skin condition and/or a skin condition or a low back disability that is attributable to service. As such, this evidence is new and material within the meaning of 38 C.F.R. § 3.156(a). Under these circumstances, the Board concludes that the criteria for reopening the previously denied claims for service connection for a skin condition and for a low back disability are met. REASONS FOR REMAND With regard to the Veteran’s claims for service connection for a skin condition (reopened), a low back disability (reopened), right and left knee disabilities, and an eye condition, the Board notes that the Veteran has been afforded VA examinations in connection with these claims. In this regard, the Board notes that a medical opinion or examination is required if the information and evidence of record does not contain sufficiently competent medical evidence to decide the claim, but there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies; and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran’s service or with another service-connected disability. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). Here, the Board finds the Veteran’s lay testimony proffered during his January 2021 Board hearing, and outline above, is competent evidence of recurrent skin symptoms, indicative of a current disability. Although the post-service medical records available for review by the Board do not show a current diagnosis of psoriasis or treatment for a skin condition, it is not clear that relevant private and VA medical records have been associated with the claims file. Additionally, as a skin rash is of observable nature, the Veteran is competent to testify as to its presence. The Veteran has also testified as to the onset of skin symptoms in service. Although there was no evidence of a skin condition at the time of the Veteran’s separation medical examination, the Board notes that psoriasis and other skin disabilities are prone to active and inactive phases; as such, the fact that a skin disability was not noted at separation from service will not be held against the Veteran, especially in light of the fact that the Veteran’s STRs were destroyed in the fire at the NPRC. Again, the Board points out that in such cases, VA’s duty to assist is heightened. See Moore, supra. Accordingly, the Board finds that the low threshold to trigger VA’s duty to provide the Veteran with an examination and obtain a medical opinion in connection with the Veteran’s claim for service connection for a skin condition has been met and the matter is therefore remanded for such. See McLendon, supra. For the same reasons, the Board finds that the low threshold to trigger VA’s duty to provide the Veteran with an examination and obtain a medical opinion in connection with the Veteran’s claim for service connection for a low back disability has been met. See id. Indeed, the Veteran’s post-service medical records show treatment for back pain for back pain and record a diagnosis of lumbar spondylosis. The Veteran has also reported an in-service incident to which he attributes that start of his back symptoms and has testified that he has experienced back pain since. The Board finds no reason to discount the Veteran’s lay statements or find that he is not credible to his reporting of such, especially in light of the fact that the Veteran’s STRs have been destroyed. Accordingly, the issue of entitlement to service connection for a low back disability is also remanded for the Veteran to be afforded a VA examination in connection with that claim. Regarding the Veteran’s claims for service connection for right- and left-knee disabilities, the Board notes that the Veteran’s post-service treatment records show treatment for complaints of bilateral knee pain and contain a diagnosis of osteoarthritis of both knees. During his January 2021 Board hearing, the Veteran testified that he began to experience bilateral knee pain in service, the onset of which was after he was tasked with carrying heavy materials, such as tents and generators, to the field for training exercises while stationed in Germany. The Board finds no reason to discount the Veteran’s lay statements or find that he is not credible to his reporting of such, especially in light of the fact that the Veteran’s STRs have been destroyed. Accordingly, the issue of entitlement to service connection for a low back disability is also remanded for the Veteran to be afforded a VA examination in connection with that claim. See McLendon and Moore, both supra. With regard to the Veteran’s claimed eye problems, the post-service medical records show that the Veteran was seen in 2015 for progressively decreased vision, bilaterally. Imaging studies showed enhancement of the posterior globe in the right eye. In July 2015, it was indicated that the Veteran had a cataract removed three months prior, and in August 2015, the Veteran was noted to have a retinal tear, left eye. When asked about his eye problems during his January 2015 hearing, the Veteran reported worsening and recurrent eye problems and asserted his belief that his eye problems may be the result of tear gas training in service. The Veteran reported experiencing itchy eyes at the time and stated that he first sought treatment for his eyes in the 1950s or 1960s. Given the existence of various current eye conditions and in consideration of the Veteran’s lay testimony, the Board finds that whether the exists an association between the Veteran’s military service, to include any tear gas training, and his later development of various eye conditions is a medical determination that neither the RO nor the Board can make on its own. Accordingly, based on the evidence of record, and because no medical professional has addressed the etiology of the Veteran’s diagnosed eye conditions, the Board finds it necessary to obtain a medical examination and opinion in connection with the claim of service connection for an eye condition, as the evidence of record is insufficient to render a decision on the claim. See 38 U.S.C. § 5103A(d) (VA’s duty to assist also includes the duty to provide a medical examination or obtain a medical opinion “when such an examination or opinion is necessary to make a decision on the claim”); Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (the Board is prohibited from exercising its own independent judgment to resolve medical questions). Accordingly, the claim for service connection for an eye condition is remanded for the Veteran to be afforded a VA medical examination that addresses the nature and etiology of any diagnosed eye condition to include determining the likelihood that it is related to the Veteran’s reported in-service tear gas training. Lastly, with regard to the Veteran’s claim for an initial compensable rating to hearing loss, the Veteran has reported a decreased in hearing acuity since last examined by VA in July 2018. The Veteran also provided a copy of a private audiological report, which he asserts supports his claim for a higher rating; unfortunately, the audiogram results are not readable. Although the duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted, a new examination is appropriate when there is an assertion and indication of an increase in severity since the last examination. See 38 C.F.R. § 3.159; see also Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). In this case, the lay evidence proffered by the Veteran during the January 2021 Board hearing suggests a possible worsening of the Veteran’s hearing acuity. Given the possible increase in severity as well as the length of time since the last examination, the Board finds that remand is necessary for the Veteran to be scheduled for a new and contemporaneous examination to determine the current level of severity associated of the Veteran’s service-connected hearing loss. See Palczewski and Snuffer, both supra; 38 C.F.R. § 3.327(a) (duty to provide a thorough and contemporaneous examination is triggered when the evidence indicates there has been a material change in a disability or that the current rating may be incorrect). The matters are REMANDED for the following action: 1. Obtain from the Gulf Coast Veterans Health Care System, to include the Biloxi VAMC and associated outpatient clinics, such as Panama City, all outstanding records of evaluation and/or treatment of the Veteran, since July 2015. Follow the procedures of 38 C.F.R. § 3.159 for requesting records from Federal facilities. All records and/or responses received should be associated with the claims file. 2. Send to the Veteran and his attorney a letter requesting that the Veteran provide sufficient information concerning, and, if necessary, authorization to enable VA to obtain, any additional evidence pertinent to any remaining claim(s) on appeal that is not currently of record. Specifically request that the Veteran furnish, or furnish appropriate authorization to obtain, all outstanding, pertinent private (non-VA) records, to include records related to any treatment of any claimed condition. 3. After the above requested medical records development is completed, schedule the Veteran for a VA skin examination (or telehealth interview, review of the record, etc. if an in-person examination is not feasible) in connection with his claims for service connection for a skin condition. The examiner must review the claims file. Upon review of the claims file and examination of the Veteran, if feasible, the examiner should identify all current skin conditions found to be present, or present at any point during the appeal period. For each identified skin condition, the examiner should provide and opinion as to whether it is at least as likely as not (50 percent or greater probability) that any diagnosed condition is related to the Veteran’s active service, including the Veteran’s reported in-service psoriasis. In providing the requested opinion, the examiner must consider the Veteran’s description of his in-service skin symptoms, as well as of the continuity of symptoms. The examiner is reminded that the Veteran’s STRs were destroyed in a fire and, therefore, the lack on documented in-service treatment should not be held against the Veteran. Additionally, given that skin conditions are likely to have active and inactive phases, the lack of documented skin condition at the time of separation from service should also not form the basis of any negative opinion. If there is any medical reason to accept or reject the proposition that the Veteran’s reported skin symptoms in-service and thereafter represented the onset of his current disability, if found, this should be noted. Additionally, a rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). 4. After the above requested medical records development is completed, schedule the Veteran for a VA orthopedic examination (or telehealth interview, review of the record, etc. if an in-person examination is not feasible) in connection with his claims for service connection for low back and right and left knee disabilities. The examiner must review the claims file. Upon review of the claims file and examination of the Veteran, if feasible, the examiner should identify all current lumbar spine and right and left knee disabilities found to be present. For each identified disability of the lumbar spine and right and left knee, the examiner should provide and opinion as to whether it is at least as likely as not (50 percent or greater probability) that any diagnosed disability is related to the Veteran’s active service, including the Veteran’s reported in-service duties requiring him to carry heavy tents and generators. In providing the requested opinion, the examiner must consider the Veteran’s description of his in-service injuries, as well as of the onset of and continuity of symptoms. The examiner is reminded that the Veteran’s STRs were destroyed in a fire and, therefore, the lack on documented in-service treatment should not be held against the Veteran. Rather, the examiner must consider whether the current back and knee disabilities are of the type that would result from the incident as described by the Veteran. If there is any medical reason to accept or reject the proposition that the Veteran’s reported injuries and symptoms in-service and thereafter represented the onset of his current disability, this should be noted. Additionally, a rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). 5. After the above requested medical records development is completed, schedule the Veteran for a VA eye examination (or telehealth interview, review of the record, etc. if an in-person examination is not feasible) in connection with his claim for service connection for an eye condition. The examiner must review the claims file. Upon review of the claims file and examination of the Veteran, if feasible, the examiner should identify all current eye conditions found to be present. For each identified eye condition, the examiner should provide and opinion as to whether it is at least as likely as not (50 percent or greater probability) that any diagnosed condition is related to the Veteran’s active service, including the Veteran’s reported in-service tear gas training. In providing the requested opinion, the examiner must consider the Veteran’s description of his in-service injuries, as well as of the onset of and continuity of symptoms. The examiner is reminded that the Veteran’s STRs were destroyed in a fire and, therefore, the lack on documented in-service treatment should not be held against the Veteran. Rather, the examiner must consider whether the current eye conditions are of the type that would result from the incident (tear gas training) as described by the Veteran. If there is any medical reason to accept or reject the proposition that the Veteran’s reported injury and symptoms in-service and thereafter represented the onset of his current disability, this should be noted. Additionally, a rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). JAMES L. MARCH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Neilson, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.